Intake Form Name * First Name Last Name Email * Phone (###) ### #### Emergency Contact Name & Phone * Gender Identity This question is optional and helps ensure I provide the safest and most affirming care during your session.) Any none medical conditions * Have you had any recent surgery, including plastic surgery? * Have you had a professional massage before? * Yes No Do you have any difficulty lying on your front, back, or side? * Yes No Do you have any allergies to oils, lotions, or ointments? * Yes No Do you have sensitive skin? * Yes No Are there any areas you do NOT want massaged (e.g., feet, face, abdomen)? * What pressure do you prefer? Light Medium Deep Any specific areas you’d like to focus on? I understand massage is not a substitute for medical care. I have disclosed all relevant health info and will update my therapist with any changes. Yes No I understand that any inappropriate remarks or behavior will immediately end the session and I will be charged in full. * Yes No Thank you! I look forward to our session. Stay Calm!